TS08 Chap 2 Addendum G -- Data Requirements - .Chapter 2 Addendum G Data Requirements -...

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Transcript of TS08 Chap 2 Addendum G -- Data Requirements - .Chapter 2 Addendum G Data Requirements -...

  • TRICARE Systems Manual 7950.2-M, February 1, 2008TRICARE Encounter Data (TED)

    Chapter 2 Addendum G

    Data Requirements - Adjustment/Denial Reason Codes

    FIGURE 2.G-1 DENIAL CODES

    ADJUST/DENIAL REASON CODE DESCRIPTION

    4 The procedure code is inconsistent with the modifier used or a required modifier is missing.

    5 The procedure code/bill type is inconsistent with the place of service.

    6 The procedure/revenue code is inconsistent with the patients age.

    7 The procedure/revenue code is inconsistent with the patients gender.

    8 The procedure code is inconsistent with the provider type/specialty (taxonomy).

    9 The diagnosis is inconsistent with the patients age.

    10 The diagnosis is inconsistent with the patients gender.

    11 The diagnosis is inconsistent with the procedure.

    12 The diagnosis is inconsistent with the provider type.

    13 The date of death precedes the date of service.

    14 The date of birth follows the date of service.

    15 The authorization number is missing, invalid, or does not apply to the billed services or provider.

    16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate.

    17 Requested information was not provided or was insufficient/incomplete.

    18 Duplicate claim/service.

    19 This is a work-related injury/illness and thus the liability of the Workers Compensation Carrier.

    20 This injury/illness is covered by the liability carrier.

    21 This injury/illness is the liability of the no-fault carrier.

    22 This care may be covered by another payer per coordination of benefits.

    24 Charges are covered under a capitation agreement/managed care plan.

    25 Payment denied. Your Stop loss deductible has not been met.

    26 Expenses incurred prior to coverage.

    27 Expenses incurred after coverage terminated.

    28 Coverage not in effect at the time the service was provided.

    29 The time limit for filing has expired.

    30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.

    31 Patient cannot be identified as our insured.

    32 Our records indicate that this dependent is not an eligible dependent as defined.

    33 Insured has no dependent coverage.

    34 Insured has no coverage for newborns.

    HIPAA Adjustment Reason Codes Release 11/05/2007.

    1 C-70, November 26, 2014

  • TRICARE Systems Manual 7950.2-M, February 1, 2008Chapter 2, Addendum G

    Data Requirements - Adjustment/Denial Reason Codes

    35 Lifetime benefit maximum has been reached.

    38 Services not provided or authorized by designated (network) providers.

    39 Services denied at the time authorization/pre-certification was requested.

    40 Charges do not meet qualifications for emergent/urgent care.

    46 This (these) service(s) is (are) not covered.

    47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.

    48 This (these) procedure(s) is (are) not covered.

    49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.

    50 These are non-covered services because this is not deemed a medical necessity by the payer.

    51 These are non-covered services because this is a pre-existing condition

    52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.

    53 Services by an immediate relative or a member of the same household are not covered.

    54 Multiple physicians/assistants are not covered in this case.

    55 Procedure/treatment is deemed experimental/investigational by the payer.

    56 Procedure/treatment has not been deemed proven to be effective by the payer.

    58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

    60 Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.

    89 Professional fees removed from charges.

    96 Non-covered charge(s).

    97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

    98 The hospital must file the Medicare claim form for this inpatient non-physician service.

    106 Patient payment option/election not in effect.

    107 The related or qualifying claim/service was not identified on this claim.

    110 Billing date predates service date.

    111 Not covered unless the provider accepts assignment.

    112 Service not furnished directly to the patient and/or not documented.

    113 Payment denied because service/procedure was provided outside the United States or as a result of war.

    114 Procedure/product not approved by the Food and Drug Administration.

    115 Procedure postponed, canceled, or delayed.

    116 The advance indemnification notice signed by the patient did not comply with requirements.

    119 Benefit maximum for this time period has been reached.

    128 Newborns services are covered in the mothers Allowance.

    129 Prior processing information appears incorrect.

    134 Technical fees removed from charges.

    FIGURE 2.G-1 DENIAL CODES (CONTINUED)

    ADJUST/DENIAL REASON CODE DESCRIPTION

    HIPAA Adjustment Reason Codes Release 11/05/2007.

    2 C-4, November 7, 2008

  • TRICARE Systems Manual 7950.2-M, February 1, 2008Chapter 2, Addendum G

    Data Requirements - Adjustment/Denial Reason Codes

    135 Interim bills cannot be processed.

    136 Failure to follow prior payers coverage rules.

    138 Appeal procedures not followed or time limits not met.

    140 Patient/Insured health identification number and name do not match.

    141 Claim spans eligible and ineligible periods of coverage.

    146 Diagnosis was invalid for the date(s) of service reported.

    147 Provider contracted/negotiated rate expired or not on file.

    148 Information from another provider was not provided or was insufficient/incomplete.

    149 Benefit maximum for this time period or occurrence has been reached.

    155 Patient refused the service/procedure.

    166 These services were submitted after this payers responsibility for processing claims under this plan ended.

    167 This (these) diagnosis(es) is (are) not covered.

    168 Service(s) have been considered under the patients medical plan. Benefits are not available under this dental plan.

    170 Payment is denied when performed/billed by this type of provider.

    171 Payment is denied when performed/billed by this type of provider in this type of facility.

    174 Service was not prescribed prior to delivery.

    175 Prescription is incomplete.

    176 Prescription is no current.

    177 Patient has not met the required eligibility requirements.

    181 Procedure code was invalid on the date of service.

    182 Procedure modifier was invalid on the date of service.

    183 The referring provider is not eligible to refer the service billed.

    184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.

    185 The rendering provider is not eligible to perform the service billed.

    188 This product/procedure is only covered when used according to FDA recommendations.

    191 Not a work related injury/illness and thus not the liability of the Workers Compensation carrier.

    196 Claim/service denied based on prior payers coverage determination.

    199 Revenue code and procedure code do not match.

    200 Expenses incurred during lapse in coverage.

    201 Workers Compensation (WC) case settled. Patient is responsible for amount of this claim/service through WC Medicare set aside arrangement or other agreement.

    202 Non-covered personal comfort or convenience services.

    204 Payment adjusted for discontinued or reduced service.

    206 National Provider Identifier - missing.

    207 National Provider Identifier - Invalid format.

    208 National Provider Identifier - Not matched.

    213 Non-compliance with the physician self-referral prohibition legislation or payer policy.

    FIGURE 2.G-1 DENIAL CODES (CONTINUED)

    ADJUST/DENIAL REASON CODE DESCRIPTION

    HIPAA Adjustment Reason Codes Release 11/05/2007.

    3 C-70, November 26, 2014

  • TRICARE Systems Manual 7950.2-M, February 1, 2008Chapter 2, Addendum G

    Data Requirements - Adjustment/Denial Reason Codes

    214 Workers Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment.

    220 The applicable fee schedule does not contain the billed code. Please resubmit a bill with the appropriate fee schedule code(s) that best describe the service(s) provided and supporting documentation if required.

    226 Information requested from the billing/rendering provider was not provided or was insufficient/income.

    227 Information requested form the patient/insured/responsible party was not provided or was insufficient.

    228 Denied for failure of this provider, another provider or the subscriber to supply requested information.

    231 Mutually exclusive procedures cannot be done in the same day/setting.

    236 This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative (NCCI).

    239 Claim spans eligible and ineligible periods of coverage. Rebill separate claims.

    244 Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Ca